Old #4 Rod, Gun Snowmobile & Archery Club Inc.
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          Old #4 Rod, Gun, Archery, Snowmobile Club Inc .

       P. O. Box 679    Charlestown, NH 03603   (make checks payable to Old 4 rgsm)

                                         July 2011 --- July 2012

                          New Member ______ Renewing Member______

Name_________________________________Age_______DOB_________________

Address_____________________________________________Phone____________

City____________________________________State__________Zip_____________

Email_________________________________Occupation______________________

Range ______ $30.00      Archery ______$15.00      Range /Archery combo____$ 40.00

Do you need X-tra Cards for Family Members? Family Members:

_____________________________________________________Age:_____________

 _____________________________________________________Age:____________

_____________________________________________________Age:_______________

“Family members” are defined as immediate family (spouse, children) living in the household under the age of 18. Family members over the age of 16 may receive a membership card. Anyone under the age of 18 must be in the company of an adult club member, while at the range.

When you receive your membership card, you will also receive information regarding range regulations and hours. You are agreeing to abide by those rules when you accept your membership card. If not in agreement, immediately return membership package to the above address for a full refund.

Would you be willing to help if contacted? Please circle all that apply.

Snowmobile Trails, Shooting Range, Fundraising,

Donations accepted and appreciated thank you $______